Cardiac Arrest after Local Anaesthetic Toxicity in a Paediatric Patient

Abstract

We report a case of a paediatric patient undergoing urological procedure in which a possible inadvertent intravascular or intraosseous injection of bupivacaine with adrenaline in usual doses caused subsequent cardiac arrest, completely reversed after administration of 20% intravenous lipid emulsion. Early diagnosis of local anaesthetics toxicity and adequate cardiovascular resuscitation manoeuvres contribute to the favourable outcome.

Local Anesthetic Systemic Toxicity

“…5,9,11,17,23,[32][33][34] The remaining cases resulted from neuraxial (13%: 4 of the 6 were epidural, 2 were described specifically as caudal injections), 16,20,26,29,30,38 paravertebral blocks (8.5%), 15,21,22,30 lower (8.5%) 6,7,13 and upper (8.5%) 6,31,36,39 extremity blocks, head and neck blocks (8.5%) (maxillary nerve, peribulbar), 14,19 topical, 28,35,37 transabdominis plane blocks, 8 and intravenous administration. 18 Seven cases (15%) involved continuous infusions of local anesthetic.…”

“…9,11,13,15,16,19,29,33,34,38 In 2 cases, the presence or absence of an intravascular marker was irrelevant. In 1 case, the local anesthetic was purposefully injected intravenously to blunt the clinical response to tracheal extubation, 18 and in another, the patient self-administered a topical preparation.…”

“…Twenty-two patients (47%) were treated with ILE. 5,[7][8][9][10][11][12]14,15,17,21,23,24,26,29,30,32,34,37,39 In 1 case report, 39 ClinOleic 20% emulsion (Baxter, Deerfield, Illinois) was used instead of ILE. Nine patients received both a benzodiazepine and ILE.…”

Analysis of efficacy of adding dexamethasone to ropivacaine in oral surgery

“…Međutim, studije ukazuju da dodatak adrenalina bupivakainu utiče na jače ispoljavanje njegove kardiotoksičnosti 6 . Intravaskularna ili intraosealna primena bupivakaina može dovesti do akutnog srčanog zastoja i smrti pacijenta 7,8 . Posle izveštaja o neželjenim efektima bupivakaina (kardiovaskularni kolaps, smrt posle slučajne intravenske primene), ropivakain je uveden u kliničku upotrebu u ginekologiji, ortopediji, urologiji, neurohirurgiji i drugim hirurškim granama za postizanje regionalne anestezije 9 .…”

“…However, studies show that adrenaline added to bupivacaine increases its cardiotoxicity 6 . Intervascular or interosseous administration of bupivacaine may lead to acute cardiac arrest and patient death 7,8 . After adverse effects of bupivacaine had been reported (cardiovascular collapse, death following accidental intravenous administration), ropivacaine was introduced into clinical use in gynecology, orthopedics, urology, neurosurgery and other surgical branches for achieving regional anesthesia 9 .…”